Language
English (US)
Southeastern Cardiology Associates
Annual Established Patient Paperwork
Patient Name
Date of Birth
-
Month
-
Day
Year
Date
Gender/Sex
Male
Female
Social Security Number
Marital Status
Married
Single
Widowed
Divorced
Preferred Language
Ethnicity
Hispanic/Latino
Not Hispanic/Latino
Race
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Home Phone Number
Please enter a valid phone number.
Work Phone Number
Please enter a valid phone number.
Cell Phone Number
Please enter a valid phone number.
Employer/Occupation
Email
example@example.com
Web-Enable for Patient Portal
Yes
Emergency Contact
Name
Relationship
Phone Number
Please enter a valid phone number.
Primary Care Provider
City, State of Primary Care Provider's Practice
Primary Care Provider's Phone Number
Please enter a valid phone number.
Primary Insurance Provider
Insurance Policy/Subscriber Number
Insurance Group Number
Secondary Insurance Provider Name
Insurance Policy/Subscriber Number
Insurance Group Number
If your insurance is provided through someone other than yourself please list their information below
Name
Date of Birth
-
Month
-
Day
Year
Date
Social Security Number
Signature
Clear
Today's Date
-
Month
-
Day
Year
Date
Back
Next
Southeastern Cardiology Established Patient Paperwork
Please review the HIPAA Acknowledgement below before signing this form.
Patient's Signature
Clear
Today's date
-
Month
-
Day
Year
Date
Back
Next
Southeastern Cardiology Alternative Communication Form
Please review the document below before completing this form
I authorize Southeastern Cardiology Associates, in regards to my protected health information:
To speak with anyone listed on the Right to Share information list, and give my prescriptions to them as indicated below
To speak only with me
Right to Share Information with Family and Friends
Name
Yes, can pick-up prescriptions
No, cannot pick-up prescriptions
Name
Name
Name
Name
Patient's Name
Patient's Date of Birth
-
Month
-
Day
Year
Date
Patient's Signature
Clear
Today's Date
-
Month
-
Day
Year
Date
Back
Next
Southeastern Cardiology Consent to Routine Procedures and Treatments
Please review the consent document below before signing.
Patient's Signature
Clear
Today's date
-
Month
-
Day
Year
Date
Back
Next
Southeastern Cardiology Financial Policy
Please review the financial policy below before signing this form.
Patient's Name
Patient's Signature
Clear
Today's Date
-
Month
-
Day
Year
Date
Back
Next
Southeastern Cardiology Records Release
Please review the Records Release below before signing this form.
Patient's Name
Patient's Date of Birth
-
Month
-
Day
Year
Date
Last 4 digits of Patient's Social Security Number
Is there any information you do not want disclosed between your providers?
Patient's Signature
Clear
Back
Next
Southeastern Cardiology Testing Cancellation Policy
Please review the policy below before signing this form.
Patient's Signature
Clear
Preview PDF
Submit
Should be Empty: